Assessing Fluid Responsiveness Using Noninvasive Hemodynamic Monitoring in Pediatric Shock: A Review
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AbstractNoninvasive hemodynamic monitoring devices have been introduced to better quantify fluid responsiveness in pediatric shock; however, current evidence for their use is inconsistent. This review aims to examine available noninvasive hemodynamic monitoring techniques for assessing fluid responsiveness in children with shock. A comprehensive literature search was conducted using PubMed and Google Scholar, examining published studies until December 31, 2022. Articles were identified using initial keywords: [noninvasive] AND [fluid responsiveness]. Inclusion criteria included age 0 to 18, use of noninvasive techniques, and the emergency department (ED) or pediatric intensive care unit (PICU) settings. Abstracts, review papers, articles investigating intraoperative monitoring, and non-English studies were excluded. The methodological index for nonrandomized studies (MINORS) score was used to assess impact of study bias and all study components were aligned with Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. Our review yielded 1,353 articles, 17 of which met our inclusion criteria, consisting of 618 patients. All were prospective observational studies performed in the ED (n=3) and PICU (n=14). Etiologies of shock were disclosed in 13/17 papers and consisted of patients in septic shock (38%), cardiogenic shock (29%), and hypovolemic shock (23%). Noninvasive hemodynamic monitors included transthoracic echocardiography (TTE) (n=10), ultrasonic cardiac output monitor (USCOM) (n=1), inferior vena cava ultrasonography (n=2), noninvasive cardiac output monitoring (NICOM)/electrical cardiometry (n=5), and >2 modalities (n=1). To evaluate fluid responsiveness, most commonly examined parameters included stroke volume variation (n=6), cardiac index (CI) (n=6), aortic blood flow peak velocity (V peak) (n=3), and change in stroke volume index (n=3). CI increase >10% predicted fluid responsiveness by TTE in all ages; however, when using NICOM, this increase was only predictive in children >5 years old. Additionally, SV of 10 to 13% using TTE and USCOM was deemed predictive, while no studies concluded distensibility index by transabdominal ultrasound to be significantly predictive. Few articles explore implications of noninvasive hemodynamic monitors in evaluating fluid responsiveness in pediatric shock, especially in the ED setting. Consensus about their utility remains unclear, reiterating the need for further investigations of efficacy, accuracy, and applicability of these techniques.
